"We should demystify the term addiction"
By Hans Olav Fekjær.
Published in rus & avhengighet nr 1 1998, translated by Harald Korneliussen. I have not asked the parties in question for permission, this is an unofficial translation.
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Drug addiction, gambling addiction, internet addiction, sex addiction......
"Addiction" sounds like a scientifically justified diagnosis describing a pathological process. But does the term really represent an increased insight over the popular synonyms like to "be hooked on" something?
The word "addiction" seems to have got its current meaning through AA's theory of alcoholism. When epidemiological and experimental research had removed the basis for AA's alcoholism theory, WHO choose in 1979 - as a compromise - to replace it with "alcohol addiction syndrome". The usual interpretations show that many of the implications of the alcoholism theory now live on under the name "the addiction syndrome".
The diagnosis of addiction
The official diagnosis systems ICD and DSM currently have identical criteria for addiction to alcohol, illegal drugs and tobacco. Addiction to gambling, sex, internet etc are not mentioned, but psychologists who care about these addictions obviously use equivalient definitions.
The diagnosis systems mention 6-7 possible symptoms which can be classified into three groups:
- increased tolerance and/or abstinence problems
- signs of loss of control (strong craving/ compulsiveness or drinking more than planned or failed to cut down on use)
- damaging effects (social, health or work-related)
Currently no "symptoms" are mandatory. The addiction diagnosis demands that one has at least 3 of 6 symptoms through the previous year (ICD-10) or 4 of 7 at one point in life (DSM-IV). One does not need to have symptoms from all three groups, for instance is lack of control not a prerequsite.
Compared to regular medical diagnoses, it's remarkable that the important boundary between healthy and ill is set at an arbitrarily chosen number of symptoms (3 out of 6 or 4 out of 7)
Can "addiction" explain behaviour?
It follows from the diagnosis criteria that addiction describes a dangerous and/or harmful lifestyle. Often, however, addiction is not used merely as a description of behaviour, but as an explanation - with pretentions of diagnosticating a psychopathological process: "He does it because he is addicted"
The psychologist William Rohen(1) pointed out that "addiction" is a "ghost-in-the-machine"-explanation: We see behaviour that we cannot immediately explain, and say that there is something mystical, invisible inside man that is the cause.
"Continued use despite harmful effects" is not a clear symptom of illness, as we all can do things despite knowing that they are risky, or that we shouldn't really do them.
Recreational drugs give physical addiction, defined by increased tolerance and abstinence symptoms. This contributes to the postponement of rehabilitation. But almost all drug abusers are sober in periods. The problem is that they resume use later. Hospital patients who recieve morphine often get worse physical addiction than street users, but they accept the unpleasantness associated with withdrawal.
Lack of control was the main point in the alcoholism theory. But many people with a high consumption of drugs feel they are in control, and demonstrate it by abstention when the situation demands it. This is also shown in experimental research.
Lack of control can not explain activities we can choose to abstain completely from (drug use and gambling), merely activities we can't avoid (like eating).
Is addiction the main part of the problem?
In the area of drugs, and also gambling, it is currently common to speak as if "addiction" is the main problem.
There has been most research on the issue of alcohol. There, most of the problems are related to drunkenness among young and young adult men, not to daily drinking in those age groups which dominate alcoholist-treatment. Epidemilogical research shows consistently that when our grandparents connected alcohol problems to "drunkenness", they were more right than those who now connect it to "addiction" or "alcoholism".
The individualisation of collective problems
Our grandparents met the old social problems of alcohol and gambling through collective measures. In a poor society without professional rehabilitators, the intuitive understanding was that these were collective problems, in other words that high alcohol consumption and gambling in a society would cause problems (as science has shown in the last decades, both for alcohol and gambling). The problem-causing activities were strongly reduced through personal abstention and legal regulations. The measurable problems from alcohol reached a low point before second world war, and gambling problems were minimal until the legal deregulation of the nineties.
Even though treatment can help individuals, our current focus on addiction has probably not become popular for its results. Alcohol damages are for instance highest in those regions where consumption is highest, despite these regions having the highest number of alcoholist rehabilitators.
However, the focus on the addicted has popular consequences for society's way of fighting the problems: It implies promises that society can both have their cake and eat it, too - have plenty of alcohol and gambling without being punished by the harmful effects.
Through the media, professionals form the popular opinion. Today, most professionals in these fields earn their living by treatment of individuals. It may seem that the rehabilitators' problem is that they see many trees (individuals), but they rarely notice the forest (society's problems as a whole). The rehabilitators' professional interests are also served by a strong focus on those idividuals who seek treatment. But population studies have shown that only a very small part of problem users ever seek treatment for their problems.
Do we today have biological explanations for addictive behaviour?
Humans are born with different inherited characteristics, and behaviour ultimately consists of biochemical processes in cells. Will psychology and behavioural fields soon become subfields of genetics and biochemistry, or is that still light years away?
The biological behavioural scientists have always explained that they have made many promising finds that soon will lead to decisive breakthoughs - and therefore they of course need increased funding. In the previous years, biological researchers in the drug field have claimed that the breakthrough has partially arrived.
In 1990 reports went around the world that scientists (2) had found the "gene for alcoholism". But later studies showed that this gene occured with precisely the same frequency in regular people as in alcoholics.(3)
In Aftenposten, in the summer of 1997 we could read a statement from a norwegian drug expert: "Now we know that drugs have that in common that they increase the amount of dopamine in nucleus accumbens".(4)
By interpretations of animal studies it is currently claimed that a common biochemical "reward"-reaction occurs in drug use, laughter, sex, a good meal etc. The theory says that neurotransmittors and particularly the dopamine processes in nucleus accumbens can:
- explain why drugs are used
- soon explain why some use drugs regularly and in harmful ways
- soon give us medicines which can heal drug addiction.
But to believe that we here find the main explanation for drug use we have to disregard many known facts:
- animal experiments show that the dopamine amount in nucleus accumbens increases not only by positive stimuli, but also from negative (aversive) stimuli. It also happens with stimuli the animals try to avoid, such as pinching in the tail or electric shock.
- dopamine increase is documented for only a handful of the more than 200 drugs on the norwegian narcotics list.
- If dopamine increase was a common identifier of drugs, we could let laboratories decide whether a chemical is a narcotic. But the decision is left to the highly subjective experiences of drug users, coloured as they are by expectations, experience, surroundings and situation.
- If the central effect of the drugs was a pleasant dopamine increase, new users should also appreciate the experience. But most new users of tobacco, alcohol, opiates and cannabis dislike the effects. Appreciation has to be learned through accustomisation, in the same way as for instance the taste of coffee and beer. Only central stimulating drugs seem to be an exception.
- If joyful activitites, drug use, gambling, smoking etc had as a common main goal the increasing of dopamine in nucleus accumbens, these activities should be able to replace each other: the smoker could trade tobacco for alcohol, encouragement in the workplace would reduce the need for the daily smoke, or gambling could replace smoking and drinking.
- Drug use changes over time and is strongly affected by the factors which affect all behaviour - personal attitudes, situation and surroundings. This is not very compatible with the theory that chemical determinism is the main cause behind use.
Today's biological theories are so full of logical holes that one may wonder how they got to be as widespread as they are. A partial explanation is that biological research performed by doctors in white coats often gets a higher status than psychology and social science. Many accept the theories because they lack their own knowledge to dispute them. Biological and genetical explanations are currently "in", where chemical determinism replaces the view of man as an actively deciding individual in a social context. But how large is the transition value from rodents in american research laboratories to humans affected by their relations, values, social situation and so on?
It is a beautiful theory that humanity's joys, excesses and drug use all can be explained from a single chemical reaction. One has to think of the words of the biologist Thomas Huxley: "A beautiful theory, killed by a nasty, ugly little fact".
Addiction is a correct, but not particularly deep, description
We are currently witnessing that many exaggregated activities are classified as "addiction". For these activities
- psychologists make very similar diagnosis schemas
- rehabilitators establish treatment facilities
- epidemiologists map the extent of the problems in populations
- medical professionals collect physical signs, hoping to find biological causes to the behaviour.
The rule is that those who show exaggregated behaviour, also more than usually like this activity, even if harmful effects create an ambivalence. Therefore the behaviour does not fit psychiatric definitions of compulsive behaviour, and therefore very few seek treatment.
When professionals say that a person is "addicted", that can be entirely correct. But it is probably not particularly deep, and does not really tell us anything more than that the behaviour is exaggregated. Despite diagnosis schemas it does not say more than common people's use of the term in norwegian everyday speech. The adoption of the term by professionals is a sign of an interesting cultural shift from earlier times, a so-called paradigm shift, not that new research has shown that exaggregated use is about illness.
We shall of course not throw the baby out with the bath water. Just in case, it needs to be pointed out: to point out that the description "addicted" is an expression of common-sense and is not particularly deep, does not mean that addicted people don't need help to modify their behaviour. Old habits are often very hard to change. Drug use has been a part of their adaption to their situation in life. Think only of drug abusers who often completely lack the skills thrive in society!
Hans Olav Fekjær is chief medical officer in the office for drug affairs in Oslo.
Litterature:
The translator may be contacted at vintermann on gmail for further information. I may do amateur translations for you if you ask.
Remember the large US blogger I mentioned?
It was Michelle Malkin, by the way. To remind you, she said:
"When it comes to speaking and writing on unpleasant matters, I learned a long time ago to stop apologizing. It is a waste of my breath, time, and energy to precede every political discussion with "I'm not saying all [X] are [Y]." Or: "Of course, I don't hate all [Z] and please don't misunderstand me, blah, blah, blah." "
I thought that ironic, because obviously she doesn't extend that favour to her opponents.
But I found another example of this kind of statement on a left-blog. It's not so funny, and it's not so blatantly hypocritical, but it's all the more tragic. Jeanne of Body and Soul writes about the legitimization of torture in the US:
"[...]something profoundly evil happens to a country that's starts parsing who has the "right" to be treated as a human being. Once you take that first step, everything that happens subsequently is inevitable."
... apparently not noticing that she has just delivered a classical pro-life/anti-abortion argument.
Vårt Land recently wrote about how conservative evangelicals in the US begin to wake up to the reality of their government's complicity in torture.
Too bad I don't see them writing about passionate feminists waking up to that other horror.
Looks like I'm not the only one with the great idea of pledge auctions. There is a site, fundable.org, which implements the idea with paypal. How great! But this shows one problem with searching the net: Apparently they have been around since 2004, but although I have searched and searched for something like this, I haven't found it until now, and that by random chance (three or four links from boingboing). Not entirely random, I suppose, I was looking up some people with creative ideas, but nonetheless.
My problem was that I had only my own term for the concept (pledge auctions) and an understanding of what I meant by it. Neither could be put into a search engine - well, my own term would, but it didn't work because fundable.org calls them group auctions.
Realclimate has an interesting article about James Lovelock's predicions of doom. They take the narrow road, and treat the old man with the respect he deserves. I left this comment:
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"It's interesting to see that reading Lovelock for the first time had a similar effect on the author to what it had on me. I thought "Wow, this is really exciting!", and was a bit disappointed to find that he was regarded as something of an "enfant terrible" by respected scientists.
Today, I suppose climate scientists are pretty much the "planetary doctors" he wrote that he wanted, trying to figure out how we can keep our planet healthy in an experience-based way.
It's reassuring that his words of impending disaster find little support by the "doctors". However, there are other worrying things in the Worldwatch reports, to put it like that. Although climate modeling integrates an impressive variety of disciplines, we don't know very much about how the economy will cope, how people will behave, or even such practical questions as how much oil we've got left. There's plenty of room for disaster still, unfortunately, so the bad gut feeling of someone like Lovelock shouldn't just be dismissed.
And you didn't. Thank you for taking my old hero seriously."
Some points I feel are worth mentioning in this debacle:
I remember when the images were first printed last year. That sparked protest from norwegian and danish muslims, but no violence. So why the outrage when a small christian magazine reprints them?
Part of the explanation may indeed be the tour of the Islamic Society of Denmark, which many right wing blogs have blamed. They did bring cartoons, including three that were not printed in Jyllandsposten, and which were a lot more offensive.
The ISD members say these pictures were sent anonymously to danish muslims. The right-wing blogs (which I won't link to, you know of whom I speak) try to cast doubt on this, by adding that the ISD refused to disclose the identity of the recievers. It was dishonest to give the impression that these were printed in the newspaper, and these clerics have a lot to answer for, but the idea that the danish muslims made these images themselves I find ridiculous. They may try to raise passions and incite violence and boycotts, but they would not deliberately blaspheme against themselves. Even if they wanted to, it would be hard for them to make that kind of caricatures.
No, most likely the clerics are telling the truth when they say danish muslims recieved these anonymously, and since they probably came from the sort of violent ultranationalist we have a couple of in scandinavia, it's understandable that they want to stay anonymous. Selbekk isn't the only one to recieve death threats, muslim leaders recieve them too, from right-wingers, neonazis and "clash of civilisation"-believers.
That one of the images was a photocopied version of an image from some sort of pig-snorting contest, does not change this. I think it more likely that some racist grabbed it from the net and sent it to a muslim, than that they took it themselves, which the right-wing blogs seem to think.
The muslims in Denmark probably feel that they are under attack, and they are not entirely unjustified in that belief either. Even here in Norway we have had many laws enacted to harass muslims - I know, because my wife is catholic, and most of these laws have the side effect of greatly inconveniencing other minority churches with lots of immigrants - and Denmark is a lot more anti-immigrant than us. (Sweden once again seems the land of sanity up here).
The response of american newspapers have been interesting. AFAIK none have reprinted the images. Some speculate that because religion has a bigger place in the USA, and that there is therefore more understanding that people can take offense at blasphemy.
It seems to me like many US commentators (and blogs) underestimate anti-islamism in Europe. Prominent muslims do recieve death threats, and laws are enacted to harass them, like anti-scarf laws, laws to hinder marriage with foreigners etc. Both Denmark and Norway have privileged state religions, as well as large anti-immigrant parties and small groups of neo-nazis and the like.
Oh, and those bloggers who think that I (or others on the left) justify embassy-burnings and so on, I refer you to this campaign by SOS Rasisme (If you can't read norwegian, too bad, drop me a mail at vintermann on gmail and I'll translate). This is interesting because the anti-racism organisation SOS Rasisme is run by people from the far, far left. If these people can make so sensible statements, just how far left do you have to go to find people who ACTUALLY justify embassy burnings?*
I'm just glad those danish clerics went on tour with cartoons and hate mail, and not with images from the Srebrenica massacre or something.
* Oh, an ironic apropos. A certain large US blogger wrote:"When it comes to speaking and writing on unpleasant matters, I learned a long time ago to stop apologizing. It is a waste of my breath, time, and energy to precede every political discussion with "I'm not saying all [X] are [Y]." Or: "Of course, I don't hate all [Z] and please don't misunderstand me, blah, blah, blah.". If she applied that standard to others as well, perhaps she would see that there aren't so many "leftists" who support embassy-burnings after all.